WORK APPLICATION FORM
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
Province
Postal / Zip Code
Email
example@example.com
Best Phone Number
Format: (000) 000-0000.
ABOUT YOU
Are you ok being around potential allergens (Pets, Pollen etc)
Yes
No
Languages Spoken
How did you hear about Care Visits?
Do You Have a Valid Drivers License
Do You Own a Vehicle
Are You Comfortable Driving a Client in your vehicle?
What Attracted you to apply?
What sets you apart?
What are your personal values?
Are you willing to work in a smoking environment?
Availability for work: Select all days / times available for work on a consistent basis each month.
Rows
9-12 AM
12-1 PM
1-3 PM
3-6 PM
6-9 PM
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
SUNDAY
Areas in Edmonton you are willing to work in:
SW
NW
SE
NE
Are you currently working?
What experience do you have working with seniors?
Have you attended any health related courses or education?
EMPLOYMENT DETAILS
What is the name of your most recent employer?
Date Started
Date Completed
Reasons for leaving
Describe your duties in this position
Contact Name and Phone Number
May we contact this employer?
Yes
No
Please provide 3 References (excluding family & friends)
Please select activities you have experience / are comfortable performing
Cooking with a Senior
Shower Assist
Medication Assistance
Light Housekeeping
Tasks around the house
Laundry/ironing
Changing bed linens
Play cards/puzzles/crafts
Go for a walk
Use the computer
Have you had a criminal record search completed within the last 12 months?
Have you ever been arrested?
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